A 13-year-old boy suffers a brief loss of consciousness while playing football. The CT scan performed in the ER shows a 5 cm temporal lobe cyst, without shift of structures or blood products. The child's examination in the ER is normal and he is released with an appointment to obtain an MRI and consultation with the local neurosurgeon.
The neurosurgeon suggests that surgery is one possible method of treatment and, given the large size of the cyst, is in favor of performing surgery. The family sought a second opinion locally but the second opinion "deferred" to the opinion of the first neurosurgeon.
The introductory letter of consultation from the child's primary care doctor clearly stated that the child never had any symptoms prior to discovery of the cyst, had made a complete recovery, and had a normal neurologic and ophthalmologic examination. Accompanying data included the CT and MRI, as well as the neurosurgeon's and neurologist's consultations, which documented the normal examination. Following review of all the data, the remote consultant suggested observation without surgery, with precautions and instructions for future evaluations. This opinion was supported by the medical literature. One of the questions asked by the consulting physician was the issue of the child's return to playing contact sports with such a large cyst. The available,, albeit limited citations, were provided to the consulting doctor with the suggestion that there is some increased risk, but that the level of concern was based on case reports only. The ultimate decision was deferred to the patient's parents.
Follow-up reports indicated that both the referring doctor and patient's family were pleased with the opinion, both with the approach at reaching the opinion as well as with the medical evidence.